Victoria Infirmary

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture

At our last assessment, we rated this key question as requires improvement. At this assessment, the rating has changed to Good.

This service scored 68 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who work for them.

Staff feedback included concerns the flexible working arrangements and rotas were not equitable.

Staff were knowledgeable about the equality act and training had been given.

The workforce equality, diversity and inclusion should be reviewed as part of the service review.

The service had leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively.

Staff told us historically leaders were not approachable and did not respond to concerns raised. Following our last inspection, we found changes had been made to the leadership team and staff felt more support for the service was prioritised as a service review had begun.

The service fostered a positive culture where people felt they could speak up and their voice would be heard. The service had Freedom to Speak up Guardians and champions in place. Staff were aware of how to raise concerns. Some staff felt there was still work to do in this area.

The service valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who work for them.

Staff feedback included concerns the flexible working arrangements and rotas were not equitable.

Staff were knowledgeable about the equality act and training had been given.

The workforce equality, diversity and inclusion should be reviewed as part of the service review.

The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They act on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

Leaders and managers supported staff, and all staff we spoke with were clear on their individual roles and responsibilities. Managers met with staff regularly to complete appraisals and performance reviews. The provider had established governance processes that were appropriate for their service. Staff could access all required policies and procedures.

Staff told us they would like to care for other medical conditions they had been trained in, as some staff felt they were not using all the skills they had. Leaders told us this would be considered as part of the service review.

However, staff reported some risk around staffing during periods of high staff absence and the ability to cover the shifts. Leaders had not considered this and it had not been identified and added to the risk register.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

The service had an exclusion and triage system in place and signposted patients accordingly. The service worked with GP practices and Leighton Hospital Emergency Department primarily and other services when required.

The service did not always focus on continuous learning, innovation and improvement across the service. A service review was in progress but had not been completed in the last four years.

We saw evidence of some service improvement following an incident. For example, changes to the venous thromboembolism pathway.